"Continuing Care Provider Application for New or Renewal Certificate of Registration" - Kansas

Continuing Care Provider Application for New or Renewal Certificate of Registration is a legal document that was released by the Kansas Insurance Department - a government authority operating within Kansas.

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STATE OF KANSAS
KANSAS INSURANCE DEPARTMENT
CONTINUING CARE PROVIDER
APPLICATION FOR NEW OR RENEWAL
CERTIFICATE OF REGISTRATION
To the KANSAS COMMISSIONER OF INSURANCE, Topeka, Kansas:
On behalf of the __________________________________________________________
of ________________________________, ____________________________________,
(City)
(State)
(Zip)
a continuing care provider created under the laws of the state of ____________________
I hereby apply for a CERTIFICATE OF REGISTRATION pursuant to K.S.A. 40-2231
through K.S.A. 40-2238, authorizing and empowering the above named continuing care
provider to operate in the State of Kansas until such certificate is suspended, revoked or
terminated by the Insurance Commissioner of Kansas.
It is hereby certified the continuing care provider making this application has complied
with the requirements of K.S.A. 40-2231 through K.S.A. 40-2238.
Finally, the undersigned swears under oath (s)he has executed this application dated
__________________ for and on behalf of __________________________________,
that (s)he is a duly appointed representative of such provider, that (s)he is authorized to
execute and file this application, and that the information contained in this application is
true and accurate to the best of his/her knowledge.
_______________________________________
Signature of Applicant
(Chief Executive Officer or Executive Director)
Please note the following requirements:
• NEW APPLICATION – please complete the attached Annual Disclosure
Statement.
• RENEWAL APPLICATION – please attach a copy of your most recent Annual
Disclosure Statement.
• ALL APPLICANTS – please attach annual certification audit of most recent
fiscal year and copies of any continuing care contract forms.
STATE OF KANSAS
KANSAS INSURANCE DEPARTMENT
CONTINUING CARE PROVIDER
APPLICATION FOR NEW OR RENEWAL
CERTIFICATE OF REGISTRATION
To the KANSAS COMMISSIONER OF INSURANCE, Topeka, Kansas:
On behalf of the __________________________________________________________
of ________________________________, ____________________________________,
(City)
(State)
(Zip)
a continuing care provider created under the laws of the state of ____________________
I hereby apply for a CERTIFICATE OF REGISTRATION pursuant to K.S.A. 40-2231
through K.S.A. 40-2238, authorizing and empowering the above named continuing care
provider to operate in the State of Kansas until such certificate is suspended, revoked or
terminated by the Insurance Commissioner of Kansas.
It is hereby certified the continuing care provider making this application has complied
with the requirements of K.S.A. 40-2231 through K.S.A. 40-2238.
Finally, the undersigned swears under oath (s)he has executed this application dated
__________________ for and on behalf of __________________________________,
that (s)he is a duly appointed representative of such provider, that (s)he is authorized to
execute and file this application, and that the information contained in this application is
true and accurate to the best of his/her knowledge.
_______________________________________
Signature of Applicant
(Chief Executive Officer or Executive Director)
Please note the following requirements:
• NEW APPLICATION – please complete the attached Annual Disclosure
Statement.
• RENEWAL APPLICATION – please attach a copy of your most recent Annual
Disclosure Statement.
• ALL APPLICANTS – please attach annual certification audit of most recent
fiscal year and copies of any continuing care contract forms.
________New ($50 fee)
________ Renewal ($25 fee)
Administrative
Office:
___________________________________________________________
(Street Address)
___________________________________________________________
(City)
(State)
(Zip)
______________
________________
_____________________
(Phone)
(Fax)
(Email Address)
Continuing Care
Facility:
___________________________________________________________
(Street Address)
___________________________________________________________
(City)
(State)
(Zip)
____________________________
(Phone)
Chief Executive
Officer/Executive
Director:
___________________________________________
(Name)
___________________________________________
(Title)
___________________________________________
(Phone Number)
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